Executive summary
On 31 October 1994 the Locomotive Engineer on Train 776, a northbound express freight operated by New Zealand Rail Limited (NZRL) advised Train Control that he was at Oaro, and in response to the question from the Train Control Officer, cancelled the track warrant he held to Oaro. A southbound passenger train, Train 701, arrived at Oaro to cross 776, but 776 was not there. Subsequently it was discovered that 776 was at Claverley, some 12 kilometres south of Oaro. A track warrant was issued for 701 to continue southwards. When the planned crew changeover occurred at Claverley, the Locomotive Engineer who moved from 701 to 776 discovered that the track warrant for 776 to travel to Oaro had not been cancelled as required by NZRL rules. The safety deficiencies addressed in this report are fitness for duty; the auditing of the compliance with rules and procedures by operating staff and the working conditions of Train Control Officers; the relief of staff involved in operating irregularities; and the resilience of the Track Warrant Control system on NZRL.
Related Recommendations
Establish procedures, with safeguards, for maintenance work in Train Control offices to ensure that Train Control Officers are not unreasonably hampered in the execution of their duties.
Review the adequacy of existing audit procedures to assess compliance with Track Warrant Control Rules.
Review the adequacy of existing procedures for assessing fitness for duty for Locomotive Engineers and Train Control Officers.
Continue to take steps to assess the safety culture among operating staff involved with Track Warrant Control and introduce programmes and procedures to improve it if deficiencies are noted.